How the idea became lawH.R.3590

Patient Protection and Affordable Care Act

Jared P. Wagner, MD

Feburary 2009

• In his first address to a full session of congress, President Obama discusses health care reform.

“health care reform cannot wait, it must not wait, and it will not wait another year.” – Obama February 24, 2009.

April 2009• Senate Finance Committee Chairman Max Baucus,

D. Montana begins a series of roundtable discussions. • Initial debate centers around how to

finance the effort and how to best expand coverage to the uninsured.

• Senator Arlen Spector leaves the Republican party announcing that he will run for reelection in 2010 as a Democrat.• There are now 60 senate Democrats

Senate Mechanics• Senate rules requires a supermajority of votes to end

debate legislation and advance to a final vote. • Total of 60 votes out of 100 Senate members is needed.• Controversial bills are unlikely to advance to a final vote unless 60

supporters can be found. • Preventing a bill from coming to a vote for lack of 60 votes is referred

to as a filibuster.

• The one exception to this rule is a process called reconciliation.• Allows a bill automatically advance to a final vote. Only 50 votes are

needed.• Strictly limited to mandatory spending programs or taxes.• Must reduce the federal deficit over a 10 year period.• Cannot include non budget related items

• Insurance regulations

March 2009 • American’s Health Insurance Plans (AHIP)

declares they are willing to cover preexisting conditions if everyone is required to carry health insurance.

• American’s Health Insurance Plans (AHIP) a national association representing nearly 1300 member companies. • AHIP support meant there would not be large scale

opposition from the insurance industry

June-July 2009 • Work on the Senate Finance committee shits to a small

group of six senators 3 Republicans and 3 Democrats. Democrats Republicans Max Baucus (MT) Olympia Snow (ME) Kent Conrad (ND) Michael Enzi (WY) Jeff Bingaman (NM) Charles Grassley (IA)

• These senators come to be called the gang of six.• Obama and Congressional leaders the six to represent

the best chance for a bipartisan deal.• Several controversial Democratic ideas are dropped.

Dropped Replaced WithPublic Option Private but regulated exchangesIncome surtax on high earners Tax on high-end insurance plans

August 2009• Congress adjourns for summer recess

– Senators and congressmen across the nation hold a series of town hall meetings to explain the health care legislation.

– These meeting are frequently disrupted by angry protesters.

• Senator Ted Kennedy loses battle with cancer.– Potential democratic votes (59)

Death Panel Scare

• Rumors that the health care law would establish “death panels” to determine who deserved health care.

• In August, 2009 Sarah Palin wrote• “The America I know and love is not one in which

my parents or my baby with Down Syndrome will have to stand in front of Obama’s ‘death panel.”

• President Obama subsequently held a meeting where he stressed that his plan would “not pull the plug on grandma”.

• The source of the concerns the ability for a primary care physician to obtain reimbursement for talking with a patient about end of life care was quickly removed from the legislation.

September 2009 • Senators Baucus bipartisan “Gang of Six” talks collapse

ending the possibility of broad bipartisan consensus. • Of the original three Republicans Only Olympia Snow, R (MA)

continues to support the bill.

• Senator Paul Kirk, D is sworn in as in interim senator to fill Ted Kennedy’s seat until an election is held in January 2010.

• Potential democratic votes (60)

October 2009• The health care bill passes the Senate

Finance Committee on a vote of 14-9. • Senate Majority Leader Harry Reid merges

the Finance Committee’s bill with the work of another senate committee. – The merged bill adds a

government run public insurance option.

– Olympia Snow states her opposition to the merged bill.

November 2009• The House of Representatives passes its health

care reform bill by a vote of 220-115.– House bill has a public option– House bill pays for reform by increasing income tax

by 5.4% on wealthily Americans (income > $5,000)

• Reports emerge of Democratic opposition to the bill in the senate. – Mary Landreiu (LA) Opposed to public option

– Joe Lieberman (CT) Opposed to public option

– Ben Nelson (NE) Opposed to abortion funding

December 2009• A number of compromises were done in the senate to

resolve opposition.– Public option dropped from the senate bill.

– Deal is with senator Nelson allowing states to prohibit abortion coverage for health insurance plans issues on the new health care exchanges.

• As a result on December 24th the senate overcomes a unified republican filibuster to pass legislation 60-39. – No Republicans vote for measure.

– One Republican hospitalized and unable to vote.

January 2010• Efforts are made to combine the House and Senate

bills into a final common bill.– Such a bill would have be passed by both the Senate and

the House again.

• January 15th House and Senate leaders say they are close to a deal.

• Plans disrupted on January 19th when Scott Brown, Republican wins the Massachusetts special election.– Potential senate democratic votes (59).

• House and Senate talks cease.– Senate no longer has the needed votes.

Feburary 2010• No major movement on health care legislation.

• Major news organizations announce that health care reform may be dead.– ABC News

• “Health care is effectively dead,” - ABC News’ senior political correspondent Rick Klein

– Fox News• “Prince Harry (Harry Reid) has to accept the fact that his health care bill is

dead.” – Sean Hannity

– Fox & Friends

– Weekly Standard

– Washington Post

– New York Post

March 2010• Decision is made to attempt to pass the Senate bill

unchanged in the House of Representatives.– Removes the need for another (60) vote in the Senate.– Problem… Senate bill not popular in the more liberal House.

• To build sufficient support in the House the Senate agreed to pass a series to tweaks to be passed through reconciliation.– Eliminating special deals given to some states (Nebraska).– 3.8% tax on investment income for those > $250,000 annually.– Funds from tax to close the medicare “donut hole” by 2020.

• March 21, 2010 Houses passes the senate’s version 219-212.

• March 25, 2010 Senate passes reconciliation “fixes” by a vote of 56-43.

• March 31, 2010 Health care reform signed into law.

The First Year• The health care bill included a number of

provision set to kick in over the first year.

• These were designed show the public an immediate benefit from the legislation with the hope of increasing public support.

Effective Immediately• Young adults are now able to stay on their

parents’ insurance until their 26th birthday.

• Insurers not permitted to deny children coverage based on preexisting conditions.

• Tax credit for small businesses (less then 25 employees) that offer health insurance.– Credit for up to 35% of health care expenses.

Effective Within Three Months Early 2010

• Individuals who can demonstrate inability to obtain coverage due to pre-existing conditions will be able to purchase it from special high-risk insurance pools.– Funded by government– Temporary and active until 2014 – Replaced by insurance exchanges

• New plans will be required to implement an appeals process for coverage determinations and claims.

Effective Within Six Months Mid-Late 2010

• New insurance policies must provide coverage for preventive services without co-pays.

• Insurers can no longer cancel policies except in cases of fraud.

• Insurers can no longer set lifetime coverage caps on new policies.

• Medicare recipients who have fallen into the coverage gap (“donut hole”) for Medicare prescriptions will receive a $250 rebate.

Medicare and the Donut Hole• Medicare patients pay for their prescription

needs until a deductible of around $300 is met.– After the deductible is me Medicare covers 75% of

prescription costs until total cost reach approximatally $2,800

• Once medication costs reach $2,800 the patient pays 100% of drug cost until total costs approach $6,200 when the costs are considered to be catastrophic. (The Donut Hole)

• In 2010 seniors who fall into this payment range will get a $250 rebate, the first in a series of gradual closings of the gap phased in through 2020.

Thank You